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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801999
Report Date: 10/30/2024
Date Signed: 10/31/2024 09:51:06 AM

Document Has Been Signed on 10/31/2024 09:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:EDNA'S RESIDENTIAL CARE IIIFACILITY NUMBER:
565801999
ADMINISTRATOR/
DIRECTOR:		EDNA DANGIAPOFACILITY TYPE:
740
ADDRESS:1258 BEECHWOOD STREETTELEPHONE:
(805) 200-8156
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:44 PM
MET WITH:Edna DangiapoTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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LPA Conway Final printed report before completing the "Inspection Tool".

An annual continuation was generated to be able to complete the Inspection Tools and generate Notes and Technical Advise.

Please find annual report under LIC 809 - FER - Visit Date 10/30/2024 Visit Type REQUIRED - 1 Year **Recorded** and two continuation LIC 809-C - FER - Visit Date 10/30/2024 **Recorded**
Desaree PereraTELEPHONE: (818) 596-4347
Valeria ConwayTELEPHONE: (818) 454-0485
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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